POMONA, CA - Federal inspectors documented serious health and safety violations at Country Oaks Care Center during a March 2025 inspection, including improper medication handling, inadequate infection control practices, and facility maintenance issues that potentially exposed residents to health risks.
Medication Management Failures Put Residents at Risk
Inspectors identified critical breakdowns in the facility's medication management systems that could have compromised patient care. In one case involving a resident with severe cognitive impairment who required specialized nutrition through a gastrostomy tube, nursing staff administered only half the prescribed dose of eye drops needed to treat dry eyes.
The resident's physician had ordered two drops of Polyvinyl Alcohol Ophthalmic Solution in both eyes every 12 hours, but inspectors observed a Licensed Vocational Nurse administering only one drop to each eye. When questioned, the nurse acknowledged the error, stating "Resident 50 would not get the adequate dose of the medication as ordered by the physician."
This type of medication error can have significant consequences for residents with dry eye conditions. Insufficient lubrication can lead to corneal damage, increased infection risk, and progressive deterioration of eye health. For nursing home residents who cannot advocate for themselves or communicate discomfort effectively, proper medication administration becomes even more critical.
The facility also failed to maintain proper accountability for controlled substances. Inspectors found missing signatures on narcotic count logs between nursing shifts on March 1, 2025, creating gaps in the chain of custody that could potentially allow for medication diversion. Federal regulations require that controlled substances be counted and verified by both outgoing and incoming nurses at every shift change, with both nurses signing documentation to confirm accuracy.
Improper Handling of Feeding Tubes Creates Safety Concerns
Perhaps most concerning was the discovery that unlicensed nursing assistants were performing medical procedures beyond their scope of practice. Inspectors observed a Certified Nursing Assistant disconnecting gastrostomy tube feeding equipment from a resident with severe cognitive impairment and swallowing difficulties.
Gastrostomy tubes provide essential nutrition for residents who cannot safely swallow food or liquids. These medical devices require careful monitoring and should only be handled by licensed nursing personnel. When asked about the incident, the CNA stated "I disconnected the GT feeding from the resident and hung the tubing on the GT machine. I turned [the machine] off and on."
Licensed nursing staff confirmed this was inappropriate, with Licensed Vocational Nurse staff stating that "CNAs should not turn on or off the GT machine because they were not licensed to do it." The facility's Director of Nursing acknowledged that such actions were outside the CNA's scope of practice.
Improper handling of feeding tubes can lead to serious complications including aspiration, infection, tube displacement, or interruption of essential nutrition. When unlicensed staff manipulate these medical devices, it increases the risk of life-threatening complications for vulnerable residents who depend on tube feeding for survival.
Infection Control Lapses Threaten Resident Health
Inspectors documented multiple failures in infection prevention protocols that could facilitate the spread of dangerous pathogens throughout the facility. Staff failed to follow proper personal protective equipment procedures when caring for residents with confirmed or suspected infections.
In one instance, a Respiratory Therapist providing tracheostomy care to a resident under enhanced barrier precautions failed to properly secure an isolation gown. The loose gown allowed the therapist's clothing to contact the resident's bed, potentially spreading multidrug-resistant organisms. The therapist acknowledged the error, stating the "isolation gown was required for infection control purposes and a loose gown could lead to contamination and potential spread of infection to other residents."
Another infection control violation involved a Certified Occupational Therapy Assistant who provided care to a resident on contact isolation for suspected C. difficile infection without wearing required gloves and gown. C. difficile is a dangerous bacterial infection that can cause severe diarrhea, colitis, and in some cases, death. It spreads easily through environmental contamination and requires strict isolation precautions.
Healthcare-associated infections are a leading cause of morbidity and mortality in nursing homes. Residents in long-term care facilities are particularly vulnerable due to advanced age, chronic medical conditions, and compromised immune systems. Proper infection control measures are essential to prevent outbreaks that could affect multiple residents and staff members.
Food Safety Violations Risk Foodborne Illness
Kitchen staff failed to follow basic food safety protocols during meal preparation, creating conditions that could lead to foodborne illness among residents. Inspectors observed a cook handling ready-to-eat bread without changing gloves after touching contaminated surfaces including tables and oven equipment.
The facility's Dietary Supervisor confirmed this violated food safety standards, explaining that "staff should not transfer potential bacteria from surfaces like tables to the food directly, which can lead to a food borne illness for the residents." Federal food safety guidelines require single-use gloves to be changed between different tasks and after touching potentially contaminated surfaces.
Nursing home residents face elevated risks from foodborne illnesses due to weakened immune systems and underlying health conditions. What might cause mild symptoms in healthy adults can result in serious complications or death in frail elderly residents.
Inadequate Psychotropic Medication Oversight
The facility failed to ensure appropriate use of psychotropic medications, prescribing Ativan for a resident without proper diagnostic justification. The anti-anxiety medication was ordered for "agitation" rather than a specific medical diagnosis, violating federal requirements for psychotropic drug use in nursing homes.
The facility's Director of Nursing acknowledged the problem, stating that "agitation is not a specific diagnosis or indication for Ativan use." Federal regulations require psychotropic medications to treat specific diagnosed conditions documented in the clinical record, not vague symptoms like agitation.
Inappropriate use of psychotropic medications in nursing homes has been linked to increased falls, cognitive decline, and higher mortality rates. These powerful drugs can cause sedation, confusion, and other serious side effects, particularly in elderly residents with multiple medical conditions.
Additional Issues Identified
Inspectors documented several other violations affecting resident safety and quality of life. Eleven resident rooms failed to meet minimum space requirements, with three-bed rooms measuring only 190 square feet instead of the required 240 square feet (80 square feet per resident). While staff reported they could still provide care, the cramped conditions could complicate emergency responses and limit privacy.
A bathroom serving multiple residents was found in unsanitary condition with potential mold, rust, and drywall dust that could cause respiratory problems for residents with compromised health.
The violations documented at Country Oaks Care Center reflect systemic problems in staff training, policy implementation, and quality oversight. Each deficiency represents a failure to meet basic standards designed to protect some of society's most vulnerable individuals. Federal regulations require nursing homes to provide safe, high-quality care that maintains residents' dignity, health, and well-being.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Country Oaks Care Center from 2025-03-06 including all violations, facility responses, and corrective action plans.
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